Chapter 17: Functional Progressions and Functional Testing in Rehabilitation

1. Chapter 17: Functional Progressions and Functional Testing in Rehabilitation

2. Disability • The restrictive influence that disease and injury exert upon neuromotor performance • Rehabilitation • Should focus on neuromuscular coordination and agility, not just strength and endurance • Simply reducing signs and symptoms associated with injuries will not ensure a full, safe and effective return to activity • Focus on returning to pre-injury levels of function • Function • Patterns of motion that use multiple joints acting with various axes and in multiple planes • Must be sure to stress both single and multiplanar motion during rehabilitation

3. Role of Functional Progression • Must adapt rehabilitation to sports-specific demands • Simple rehabilitation activity will not predict abilities of the injured athlete • Can the athlete endure the demands of full competition? • Functional progression • Succession of activities that simulate actual motor and sport skills, enabling the athlete to acquire or reacquire the skills needed to perform athletic endeavors safely and effectively

4. Requires breaking down of individual sports into individual components • Allows the athlete to focus on the parts in a controlled environment before combining them in an uncontrolled environment (competition) • Functional progression places stresses on the body in a well-planned positive and aggressive fashion • Focus on improvements necessary to meet demands • Must be a major component of normal rehabilitation

5. Benefits of Using Functional Progressions • Goals • Restore ROM and strength • Restore cardiovascular endurance • Restore proprioception, agility and functional stability • Restore confidence, reduce apprehension and anxiety • Provides both physical and psychological benefits

6. Improving Functional Stability • Provided via • Passive restraints on the ligaments • Joint geometry • Active restraints generated by muscles • Joint compressive forces • Stability is maintained by neuromuscular control mechanisms • Must be assessed through functional testing (objectively and subjectively) • Allows for assessment of ability

7. Muscular Strength • Progression allows for increased strength acquisition • Must employ the overload principle to allow for increases in static and dynamic strength • Work to fatigue with either high or low resistance • Functional progression will develop strength using the SAID principle • Must strengthen muscles dynamically, prepare for stresses that will be encountered in competition

8. Endurance • Muscular and cardiorespiratory endurance can be enhanced through a functional progression • Endurance is necessary for long-duration activity • Daily living or repeated motor function associate with sports • Functional progression will enhance muscular and cardiovascular endurance through the repetition of the individual activities and in combination with one another

9. Flexibility • Tissues will shorten or tighten in response to immobilization • Can inhibit proper function • During progression tissues are stressed within a controlled range • Must be significant enough to elongate tissue and allow it to return to proper lengths • Flexibility and mobility are critical

10. Muscle Relaxation • Involves the concerted effort to reduce muscle tension • Through functional progression an individual can learn how to recognize and control/remove through conscious relaxation • Total body relaxation that ensues relaxes the injured area • Relieves muscle guarding that can inhibit joint’s full ROM

11. Motor Skills • Coordination, agility and motor skills are complex aspects of normal function • Appropriate contractions at opportune times with appropriate intensity • Allows for transformation of strength, flexibility and endurance into full-speed performance • When injured, athlete must regain this ability • Repetition is necessary to reacquire skills • Conscious to unconscious • Intact neuromuscular system is critical

12. Functional progression helps minimize loss of normal neuromuscular control • Practice variations used with functional progression to allow athlete to re-learn various aspects of sport • Exercises must stress neuromuscular coordination and agility • Without neuromuscular coordination improvements in strength, flexibility, endurance, and performance will not occur • Must be an integral part of long term rehabilitation

13. Psychological and Social Considerations Anxiety • Caused by uncertainty about the future • Athletes experience this uncertainty due to a vague understanding of the severity of their injury and the length of time necessary for recovery • Progression can lessen anxiety • Athlete is gradually placed in more challenging situations • Allows athlete to experience success and not be concerned about failure

14. Deprivation • Athlete experiences this after losing direct contact with team and coaches for extended period of time • Functional progression allows athlete to exercise during regular team practice at the practice site • Allows athlete to remain close in proximity and socially • Less loss of team cohesion

15. Apprehension • Obstacle to performance that may serve as precursor to re-injury • Progression allows athlete to adapt to imposed demands in a controlled environment • Restores confidence = decreases apprehension • Each success builds on past success • Athlete gains a sense of control as they return to full activity

16. Components of a Functional Progression • Should begin early post-injury • Phase I • Restore joint ROM, muscular strength and endurance • Phase II • Incorporate proprioception and agility • Allows for injured area to be positively stressed to improve neurovascular, neurosensory and kinetic functions • Should allow for planned sequential activities that challenge athlete while allowing for success • Success will breed confidence = attainment of next goal

17. Neglecting a plan may lead to re-injury, pain, effusion, tendinitis, or plateau in performance • Plan should be based on individual results and performance – not time factors • Factors that must be addressed: • Physician’s expectations for athlete’s return to activity • Athlete’s expectations for his or her return to activity • Total disability of the athlete • Parameters of physical fitness for the athlete • Must keep total well-being of athlete in perspective

18. Activity Considerations • Exercise • Single activity involving simple motor skills • Involves training and conditioning effect of repetitive activity • Must use activity to regain pre-injury status • Principles for activity selection • Individuality of athlete, sport and injury • Should be positive (no increase in symptoms should occur) • Orderly progressive program should be utilized • Variety – avoid monotony

19. To minimize monotony • Vary exercise techniques used • Alter program at regular intervals • Maintain fitness base to avoid re-injury on return • Set achievable goals, re-evaluate and modify regularly • Use clinical, home and on-field programs to vary activity • Be sure to incorporate inherent demands • Physical and athletic fitness should be merged to maximize athlete response and return to previous levels

20. Designing a Functional Progression • No cookbook method • ATC is only limited by creativity • Should be initiated early in progression • Guidelines • Evaluate athlete’s current status • Review expectations of the athlete and physician • Do they work together? • Understand demands of sport and position played • May require incorporation of athlete, coach and other athletic trainers • Analyze demands that will be placed on athlete (rank order)

21. Set goals and means to assess levels of function and progress • Set parameters for return to play criteria

22. Full Return to Play • Decision requires full evaluation of athlete’s condition • Objective observation and subjective evaluation • Athlete should feel ready physically and mentally • Controlled return • Added stress to injury can slow healing and result long and painful recovery or re-injury • Criteria • Physician’s release • Pain free, no swelling • Normal ROM, strength • Completion of functional testing minus adverse effects

23. Functional Testing • Involves having athlete perform certain tasks appropriate to his/her stage in rehabilitation process in order to isolate and address specific deficits • Utilize information to determine current functional levels and set functional goals • Used as an indirect measure of strength and power • Purpose for functional testing • Determine risk of injury due to limb asymmetry • Provide objective measures of progress • Measure ability of individual to tolerate forces

24. Functional tests serve as a good correlation to functional ability • Utilize valid and reliable tests • Should look at both unilateral and bilateral function • Allows clinician to determine if athlete is compensating • Must also consider stage of healing, appropriate rest and self-evaluation

25. Limitations of functional testing • Might be limited due to lack of availability of normative values or pre-injury baseline values for comparison - subjective decisions must be made based on test results • If normative data/pre-injury status is available objective decisions can be made • Functional test should be easily understood by athletic trainer and athlete • Must consider cost efficiency, time and space demands

26. Examples of Functional Progression and TestingThe Upper Extremity • Possible functional activities that can enhance upper extremity performance • PNF, swimming, pulley machines, rubber tubing • All can be used to simulate sports activity • Must focus on proprioception and neuromuscular control • Awareness of proprioception • Dynamic stabilization restoration • Preparatory and reactive muscle facilitation • Replication of functional activities

27. Promotion of joint position sense • Activities that can be used • Isokinetic exercise • Proprioception testing devices • Goniometry • Electromagnetic motion analysis • Can be practiced with visual cue progressing to no cues • Activities can be active or passive • Can also work to reproduce specific paths of motion to increase functional component of activity • Must stress joint at both ends of ROM and at mid-range • Results in capsuloligamentous afferents and musculotendinous mechanoreceptors, respectively • Kinesthesia training can use similar activities • Requires removal of external cues

28. Dynamic stability • Stresses the training of force couples provided by scapula stabilizers and muscles of the glenohumeral joint • CKC exercises enhance coactivation • Preparation and Reaction • Incorporate rhythmic stabilization activities along with CKC exercises • Rhythmic stabilization prepares athlete for motion and improves muscle stiffness while training for reaction • Plyometrics are an excellent alternative activity • Functional Activities • Stress sports specific skills • PNF patterns can be used as early alternative to sports specific activity (more function, less stress)

29. Program should focus on core, scapulothoracic stabilizers and the glenohumeral joint • Quadruped position allows athlete to work muscles of trunk/core and upper extremity • While most activities are OKC oriented, CKC activities are important for restoration of proper function • Throwing Progression • Instruct athlete in complete and appropriate warm-up • Should incorporate throwing motion practice (slow velocity with low stress) • Progress through increasingly difficult stages

30. Shoulder serves as template for upper extremity rehabilitation and progression • Many of the activities for the shoulder are equally effective for the elbow, wrist and hand

31. Functional Testing for the Upper Extremity • Timed performance is simplest and most common means used for testing • Velocity • Controlled environment (indoors to decrease effect of weather) • Set up a standard pitching distance (60’6”) • Have athlete use a wind-up motion • Measure a maximum of 5 throws measured in mph with radar gun • Compute the mean and compare to pretest values

32. If a radar gun is not available a stop watch can be used • Assess from ball release to catch of ball • While radar gun is more accurate, using the stopwatch can be an effective tool • CKC Upper Extremity Stability Test • Tape strips 36” apart, athlete in push-up position • # of reaches across to opposite strips within 15 seconds (rest 45 seconds between trials) • Should complete 3 trials with maximal effort • Record total touches, total touches normalized via body weight, power score (multiply mean score by 68% of patients weight (weight of head, arms and trunk) • Reliable means of testing stability • Can also use sports specific drill to assess performance and readiness

33. Critical to focus on sport demand for athlete • Must focus on skill involved in sport • OKC vs. CKC • Gymnast vs. Tennis player • May require the development of a battery of tests that are appropriate for the demands to be placed on the athlete

34. Progression for the Lower Extremity • Utilizes same basic pattern as upper extremity • Can use sprint times, agility runs for time, hopping (height and distance), co-contraction tests, carioca runs and shuttle runs • Sprint test • Set distance • Run the distance for time • 3-5 sprints should be completed and the mean computed • Pre-test and post-test measures are compared

35. Agility test • Same premise as sprint test • Difference involves the course • Not just straight ahead running • Incorporates changes in direction, acceleration, deceleration, starts and stops • Other potential agility tests • Box runs • Zigzag runs • Cutting maneuvers • Figure 8 runs • Back pedaling drills • Changes in shape and size can make drills more difficult

36. Vertical Jump • Record height athlete is able to jumps (3-5 trials) • Test can also be varied • Bilateral jump vs. Single leg jump • Countermovement vs. static squat start • Approach step vs. stationary start • Upper extremity use for propulsion vs. restricted use • Co-Contraction Semicircular Test • Athlete moves about a semicircular pattern while tethered to taut Theraband using a forward facing shuffle • Athlete will complete 3 trials of 5 repetition for time • Provides a dynamics pivot shift for the ACL insufficient knee

37. Hopping Test • Single leg hop for distance • Timed hop test (ability to hop 6 meters for time) • Triple hop for distance (distance covered in 3 consecutive hops • Crossover hop (distance covered in 3 hops) • Carioca Test • Run performed for time • Run a total of 80 feet, 40 feet to the right and 40 feet to the left, both facing the same direction • Record 3 trials and calculate a mean • Shuttle Run • Four 20 feet sprints (with 3 direction changes) • Suicide sprints – sprint, touch mark and return to starting position (total time to complete drill)

38. Balance Test • Helps determine deficits in proprioception and balance • Single leg stance (hold position for time) • Can incorporate different surfaces, and eye condition • May also incorporate sports skills into test • Subjective Evaluations • Incorporation of subjective questionnaires or numeric scales to assess function

39. Carolina Functional Performance Index (CFPI) • Evaluates lower extremity functional performance • Involves a series of tests • Co-contraction test • Carioca test • Shuttle run • One-legged hop time hopping test • Normative CFPI index was determined for males and females that can be used to accurately assess functional performance • Carioca test and co-contraction test • If baseline pre-injury data is available an objective decision can be made concerning the athlete’s progress

40. Conclusions • When an athlete can safely and effectively perform all specific tasks leading up to the motor skills they can return to activity • No program will benefit every athlete and every condition – each athlete is an individual • Using multiple options will allow for athlete’s full return to pre-injury status • May allow not only for return to pre-injury status, but also ensure safer, more effective return to play